Healthcare Provider Details

I. General information

NPI: 1578018263
Provider Name (Legal Business Name): TINA SANFORD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: TINA SANFORD LPC

II. Dates (important events)

Enumeration Date: 08/23/2016
Last Update Date: 12/19/2024
Certification Date: 12/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12645 W BURLEIGH RD STE 19
BROOKFIELD WI
53005-3102
US

IV. Provider business mailing address

12645 W BURLEIGH RD STE 19
BROOKFIELD WI
53005-3102
US

V. Phone/Fax

Practice location:
  • Phone: 262-432-0670
  • Fax: 262-475-0412
Mailing address:
  • Phone: 262-432-0670
  • Fax: 262-475-0412

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number11442-125
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number11442-125
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: